Closed borders and ‘black weddings’: What the 1918 flu teaches us about coronavirus

The influenza of 1918 killed up to 100 million people. What lessons does it offer for our current health crisis?

Plagues – or, to use a more modern term, epidemics of infectious disease – pluck at our most primal fears. We have lived with them for at least 10,000 years, ever since our ancestors took up farming and built the first semi-permanent settlements. And they have always had the upper hand. They know us intimately, preying on our strengths – our sociability, our love of gossip – and turning them into weaknesses. They are always a step ahead, and once they are out, like the genie, we can’t get them back in. All we can do is limit the damage. So here we are again.

Because epidemics are frightening, it is hardly surprising that people reach for the worst possible historic comparison. The 1918 influenza pandemic, which has been distilled in the public imagination to a single black-and-white image of bedridden US soldiers, has been hauled out of mothballs to do duty as a template of what we might expect from Covid-19. But is that global human catastrophe, which killed between 50 million and 100 million people – the vast majority in the developing world – and which was largely forgotten for most of the last century, the right comparison to make?

Flu victims in an emergency hospital at Fort Riley, in Kansas, in 1918. Photograph: Associated Press

It is important to note that the Covid-19 outbreak is not yet officially a pandemic – a global epidemic. Some have accused the World Health Organization (WHO) of doing semantic cartwheels to avoid naming it as one, given the rate at which the disease is spreading, but at the time of writing roughly half of the world’s countries remain Covid-19-free.

The virus that causes the disease, Sars-CoV-2, is a new pathogen in humans, meaning we are all immunologically naive to it. It is very contagious, but we don’t yet know how lethal it is. One way of measuring this is by the case-fatality rate (CFR) – the proportion of people who fall sick who go on to die. 

Last week, the WHO provisionally quoted a CFR of 3.4%, which would be alarming if it were correct. The CFR of the 1918 flu is still being debated, mainly because there was then no reliable diagnostic test for flu, but the number usually quoted is 2.5%. Regarding Covid-19, data is sketchy for the moment, and everyone agrees it will be a while before we know the real CFR, but there’s already good evidence that many cases are going unreported – in part because those affected have very mild symptoms. That would mean the CFR is lower than 3.4% – perhaps as low as that of severe seasonal flu, which is about 0.1%.

So we could ask why we are comparing this outbreak to the 1918 pandemic, which was such an outlier, and not the two other flu pandemics that struck in the 20th century – the 1957 “Asian” flu, and the 1968 “Hong Kong” flu. Both had CFRs much closer to 0.1%, and neither killed more than 3 million people at the most. To bring the picture right up to date, we could include the 2009 H1N1 flu pandemic, which killed in the region of 600,000 people. These are still big numbers, and they dwarf those attributed to Covid-19 to date. But the 1918 flu was in a different ballpark.

At sign in the Philadelphia navy yard in 1918. Photograph: Everett/REX/Shutterstock

Another major difference between the 1918 flu and Covid-19 is that the flu mainly affected those aged between 20 and 40, while Covid-19 mainly affects those over 60. The British virologist and flu historian John Oxford, of Queen Mary University of London, calls Covid-19 “a pale reflection of 1918 where 200,000 [Britons] died quietly at home and most of them were young”. Indeed, one of the reasons the 1918 flu was so devastating was because it purged communities of their breadwinners – at a time when there wasn’t much of a social welfare safety net to catch those left behind.

Should we be comparing Covid-19 to flu at all? The viruses that cause the two diseases belong to different families. Sars-CoV-2 belongs to the coronavirus family, other members of which caused the outbreak of severe acute respiratory syndrome (Sars) in China between 2002 and 2004, and of Middle East respiratory syndrome (Mers), which began in Saudi Arabia in 2012.

Sars and Mers were far more lethal than Covid-19 – boasting CFRs of 10% and 36% respectively – but the viruses that cause all three seem to spread in a similar way. Unlike flu, which spreads rapidly and relatively evenly through a population, coronaviruses tend to infect in clusters. In theory, that makes coronavirus outbreaks easier to contain, and indeed both Sars and Mers outbreaks were brought under control before they went global. Annelies Wilder-Smith, a professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine, thinks that the unwarranted comparisons with flu may have prevented many western governments from taking the rigorous action that is needed to contain Covid-19 now, while it’s still possible. “The short-term costs of containment look high,” she says, “But they’re much lower than the long-term costs of non-containment.”

The world may have changed but containment strategies have not. Photograph: Vintage_Space/Alamy Stock Photo

Wilder-Smith is not alone in having shifted her opinion in recent weeks towards the idea that this may be the “big one” that infectious disease experts have been fearing. When such experts say “big one”, they mean a pandemic, but it’s not clear how big they mean, because they don’t want to put numbers on it. That’s understandable, if they think that much depends on what we do – or don’t do – next. Mathematical modellers – whose job it is to put numbers on things – have estimated that up to 80% of Britons could be infected, and 500,000 could die (out of a far bigger UK population than in 1918), before this outbreak recedes. But that is very much a worst-case scenario and one that assumes that containment doesn’t work.

The bottom line, then, is that Covid-19 will almost certainly not turn out to be as bad as the 1918 flu pandemic, but it could still be bad – perhaps on a par with the pandemics of 1957 or 1968. Until a vaccine becomes available – which isn’t likely for at least 18 months – containment is our only hope for slowing its spread.

Where containment is concerned, historical comparisons can help, because the techniques don’t change. Quarantine, isolation, masks and handwashing are all time-honoured methods of keeping the sick and the healthy apart, and minimising disease transmission.

One lesson governments took from 1918 is that mandatory public health measures tend to be counterproductive. Containment is much more effective if people choose to comply. But for that to happen, they need to be properly informed about the threat they face, and to trust the authorities to act in their collective interest. If either – or both – of these things is missing, containment works less than well. In 1918, most governments were caught unawares by the pandemic – because they had no disease surveillance system in place – and public information campaigns were risible.

A US army camp hospital at Aix-les-Bain, France in 1918. Photograph: Alamy Stock Photo

One of the reasons the 1918 flu came to be known as the “Spanish” flu was because Spain was neutral in the war and didn’t censor its press. Whereas the US, Britain and France – all of which had the flu before Spain – kept it out of the newspapers at first to avoid damaging morale. When they finally acknowledged it, the newspapers issued conflicting public health messages and repeated unfounded rumours – including one that German U-boats beaching in the US had deliberately sown the flu.

Germ theory – according to which infectious diseases are caused by microscopic organisms – was also relatively new. Inevitably, people found it easy to revert to more mystical, and more fatalistic, explanations of what was happening. In the deeply pious Spanish city of Zamora, for example, the local bishop defied the health authorities by ordering a novena – evening prayers on nine consecutive days – in honour of Saint Rocco, the patron saint of plague and pestilence. This involved churchgoers lining up to kiss the saint’s relics, around the time that the outbreak peaked. Zamora went on to record the highest flu-related death rate of any city in Spain, and one of the highest in Europe.

New York City, on the other hand, experienced one of the lowest death rates. The city’s inhabitants were used to public health interventions by 1918, since local authorities had orchestrated a 20-year campaign against tuberculosis. But some New Yorkers had other ideas: local papers reported on a “black wedding” in Mount Hebron cemetery, where two Jewish strangers were married in an ancient ritual to ward off plague. Meanwhile, in the business community, there was resistance to the health commissioner’s attempts to restrict attendance at places of entertainment. When Charlie Chaplin’s film Shoulder Arms was released in the autumn of 1918, Harold Edel, the manager of the Strand theatre – a cinema on Times Square – praised his customers for their impressive turnout. He died of flu a few weeks later.

The world of 2020 is vastly different from 1918. Howard Phillips, a historian of the 1918 flu at the University of Cape Town in South Africa, observes “the relative silence of organised religion” during this outbreak, compared with the 1918 pandemic. Laura Jambrina, a teacher and resident of Zamora, notes that today the church authorities have been more vocal in their public health guidance than the secular, provincial ones – advising worshippers to wash their hands and not to sprinkle holy water. Religion has, nevertheless, played a part. The South Korean cluster of Covid-19 seems to have spread via churches, while pilgrims in Iran have posted videos of themselves defiantly licking the Fatima Masumeh shrine in the city of Qom.

Many other things haven’t changed. There was a lot of fake news in 1918 and there’s a lot of fake news now – and in 2020, its volume and speed of transmission is unprecedented. Donald Trump’s grandfather died of the 1918 flu, yet Trump has been accused of misleading Americans over the Covid-19 outbreak through his tweets. Meanwhile, hashtags circulating on Italian social media – such as #FlorenceDoesntStop, #CultureAgainstFear – could partly explain the difficulty the Italian authorities are having in containing the outbreak. A prominent Italian politician, Nicola Zingaretti, announced last weekend that he had come down with Covid-19 after organising a party on the theme of #MilanDoesntStop. The Harold Edel of our day will hopefully make a speedy recovery.

There have been horrifying reports of people drinking industrial alcohol or taking cocaine to ward off Covid-19. In 1918, too, people thought alcohol would protect them, and quacks cashed in on people’s desperation by packaging up ineffective and sometimes even toxic concoctions into “elixirs” for which they charged exorbitant prices. Some of the more vivid images of this epidemic also echo those of a century ago. The Brazilian medic and writer Pedro Nava described in 1918 how, in Rio de Janeiro, footballers played to empty stadiums. The same is happening today, only now people watch the matches on TV.

Old habits also die hard; many people are still kissing each other by way of greeting. “I have to bite my tongue every time I meet someone on the street with my baby girl,” says Jambrina. “Most people will immediately touch her cheeks or kiss her.” And we seem to have forgotten that closing borders against infectious disease doesn’t work. Many countries have done so, despite the WHO’s advice, but they are now discovering that the bug is already on the inside – and they have still got to deal with it.

It’s a lesson we seem to have to learn again every time a new pandemic appears, and the kneejerk tendency to pull up the drawbridge shares xenophobic roots with another – that of blaming “the other”. In 1918, before the name “Spanish flu” caught on, Brazilians called it the German flu, while the Senegalese called it the Brazilian flu. The Poles called it the Bolshevik disease and the Danes thought it “came from the south”. Now they are blaming Chinese people.

If there is one feature of the current epidemic for which we should applaud ourselves – besides the reports that skies are blue again over Chinese cities, since traffic has come to a standstill – it is that we have managed to avoid giving this outbreak a stigmatising name. The WHO guidelines of 2015 on how to name diseases can take a lot of credit for this. So this new plague is not the Chinese flu or the pangolin flu, it’s the rather more mundane Covid-19 – just one more epidemic in a long line of epidemics that have struck fear into our hearts, and that we can still rein in if we would just listen to our brains instead.

(Source: The Guardian)

Coronavirus: China wildlife trade ban 'should be permanent'

Campaigners have urged China to apply a permanent ban on the wildlife trade following the coronavirus outbreak.

Markets selling live animals are considered a potential source of diseases that are new to humans.

There has been speculation just such a market in Wuhan could have been the starting point for the outbreak.

Getty Images

China put a temporary ban on the trade in wildlife as one measure to control the spread of coronavirus, but conservationists say it's not enough.

They argue that, in addition to protecting human health, a permanent ban would be a vital step in the effort to end the illegal trading of wildlife.

Campaigners say that China's demand for wildlife products, which find uses in traditional medicine, or as exotic foods, is driving a global trade in endangered species.

Major source of infection

More than 70% of emerging infections in humans are estimated to have come from animals, particularly wild animals.

Experts with the World Health Organization (WHO) say there's a high likelihood the new coronavirus came from bats. But it might have made the jump to a currently unknown animal group before humans could be infected.

The viruses behind Severe Acute Respiratory Syndrome (Sars) and Middle East Respiratory Syndrome (Mers) are also thought to have originated in bats. 

China is the biggest market for both legal and illegal wildlife products. AFP

But they are thought to have circulated in civet cats and camels, respectively, before being transmitted to humans.

"We are coming into contact with species of wildlife and their habitats that we were not with before," Dr Ben Embarek, with the department of nutrition and food safety at the WHO told the BBC.

"We are suddenly exposing ourselves to totally new viruses we have never been in contact with in the past.

"Therefore, we have a number of new diseases linked to new contacts between humans and previously unknown viruses, bacteria and parasites."

A recent analysis of the nearly 32,000 known land-based vertebrate species showed that around 20% of them are bought and sold on the global wildlife market - either legally or illegally.

A study by the conservation group WWF showed the illegal wildlife trade is worth around $20bn per year. It is the fourth biggest illegal trade worldwide, after drugs, people smuggling and counterfeiting.

The Sars virus was found to have come from civet cats sold in Chinese markets

The wildlife products industry is a major part of the Chinese economy, and has been blamed for driving several species to the brink of extinction.

"This health crisis must serve as a wake-up call for the need to end the unsustainable use of endangered animals and their parts, as exotic pets, for food consumption and for their perceived medicinal value," WWF said in a statement.

Dr Embarek agreed with this view.

"We want to avoid in the future having similar types of events, with new viruses that will again jump from animals to humans," he explained.

"In that regard, it makes sense over the long-term to regulate the wildlife trade both for conservation and public health reasons, because we know that there is a constant risk of dramatic events happening again."

The Chinese government, however, has made it clear the ban will be temporary.

"Raising, transporting or selling all wild animal species is forbidden from the date of the announcement until the national epidemic situation is over," said a directive issued jointly by three Chinese agencies.

Beijing did announce a similar ban during the outbreak of Sars in 2002.

But conservationists said that, a few months after the announcements, authorities relaxed the reins and the trade bounced back.

Changed scenario?

Circumstances may be about to take a turn.

In September this year, Beijing is hosting a major global meeting on natural and biological resources, known as the Convention on Biological Diversity.

The convention, signed in 1992, has the main goal of protecting global biodiversity.

A report last year by the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) found that one million species are at risk of extinction.

With the planet's sustainability as a major global agenda, China is under scrutiny not only for what it is doing within its territory but also outside.

Its Belt and Road Initiative (BRI) mega-scheme, that aims to build infrastructure across the globe to establish itself as a major global power, has been criticised for using natural resources unsustainably.

Chinese President Xi Jinping has repeatedly used the word "sustainability" while promoting the BRI in his speeches.

Recent editorials in China's state-controlled media outlets have denounced the uncontrolled wildlife market in the country.

Conservationists say the coronavirus outbreak could provide China with an opportunity to prove that it is serious about protecting biodiversity.

"We see this as an opportunity for a permanent move to end the keeping, breeding, domestication and utilisation of wildlife, not just for the purposes of meat but also for traditional medicine," said Debbie Banks, lead wildlife investigator with the London-based Environmental Investigation Agency (EIA).

Experts point to the success of the ban China has put on the import of ivory - after years of international pressure to save elephants from extinction.

But wildlife experts stress that the ban and regulation on wildlife products will need to be global - and not just in China.

(Source: BBC)

The Chinese doctor who tried to warn others about coronavirus

In early January, authorities in the Chinese city of Wuhan were trying to keep news of a new coronavirus under wraps. When one doctor tried to warn fellow medics about the outbreak, police paid him a visit and told him to stop. A month later he has been hailed as a hero, after he posted his story from a hospital bed.

"Hello everyone, this is Li Wenliang, an ophthalmologist at Wuhan Central Hospital," the post begins.

It's a stunning insight into the botched response by local authorities in Wuhan in the early weeks of the coronavirus outbreak.

Dr Li posted this picture of himself from a hospital bed on 31 January - a day before he was diagnosed with coronavirus

Dr Li was working at the centre of the outbreak in December when he noticed seven cases of a virus that he thought looked like Sars - the virus that led to a global epidemic in 2003. The cases were thought to come from the Huanan Seafood market in Wuhan and the patients were in quarantine in his hospital.

On 30 December he sent a message to fellow doctors in a chat group warning them about the outbreak and advising they wear protective clothing to avoid infection.

What Dr Li didn't know then was that the disease that had been discovered was an entirely new coronavirus.

After falling sick, Dr Li said on Weibo that he wondered why authorities were still saying no medical staff had been infected

Four days later he was summoned to the Public Security Bureau where he was told to sign a letter. In the letter he was accused of "making false comments" that had "severely disturbed the social order".

"We solemnly warn you: If you keep being stubborn, with such impertinence, and continue this illegal activity, you will be brought to justice - is that understood?" Underneath in Dr Li's handwriting is written: "Yes, I do."

He was one of eight people who police said were being investigated for "spreading rumours".

At the end of January, Dr Li published a copy of the letter on Weibo and explained what had happened. In the meantime, local authorities had apologised to him but that apology came too late.

"We hope you can calm down and reflect on your behaviour," the letter police told him to sign says

For the first few weeks of January officials in Wuhan were insisting that only those who came into contact with infected animals could catch the virus. No guidance was issued to protect doctors.

But just a week after his visit from the police, Dr Li was treating a woman with glaucoma. He didn't know that she had been infected with the new coronavirus.

In his Weibo post he describes how on 10 January he started coughing, the next day he had a fever and two days later he was in hospital. His parents also fell ill and were taken to hospital.

It was 10 days later - on 20 January - that China declared the outbreak an emergency.

Dr Li Wenliang was accused of spreading rumours

Dr Li says he was tested several times for coronavirus, all of them came back negative.

On 30 January he posted again: "Today nucleic acid testing came back with a positive result, the dust has settled, finally diagnosed."

He punctuated the short post with an emoji of a dog with its eyes rolled back, tongue hanging out.

Not surprisingly the post received thousands of comments and words of support.

"Dr Li Wenliang is a hero," one user said, worrying about what his story says about their country. "In the future, doctors will be more afraid to issue early warnings when they find signs of infectious diseases."

"A safer public health environment… requires tens of millions of Li Wenliang."

(Source: BBC)

Coronavirus: Ten passengers on cruise ship test positive for virus

At least 10 people on board a cruise ship docked in the Japanese port of Yokohama have tested positive for coronavirus, health authorities say.

Almost 300 of the 3,700 people on the Diamond Princess have been tested so far. The number of infected could rise.

The checks began after an 80-year-old Hong Kong man who had been on the ship last month fell ill with the virus.

Some 3,600 people on a second cruise ship docked in Hong Kong are also being tested.

Chinese health authorities are stepping up efforts to control the spread of the virus, with approximately 18 million people in the east of the country now required to stay at home.

In Wuhan, the epicentre of the virus, 11 large public venues including sports arenas are being turned into makeshift hospitals to provide an additional 10,000 beds for the sick. Two new hospitals have already been built there since the outbreak started.

President Xi Jinping said China's preventive measures were "achieving a positive effect", state media reported. He said China was confident and capable of winning the war against the virus, after authorities were criticised for their initial handling of the outbreak.

The WHO has declared a global health emergency over the outbreak but said it did not yet constitute a "pandemic", or the worldwide spread of a new disease.

However, the number of cases in China jumped by nearly 4,000 on Tuesday alone to more than 24,300, with another 65 deaths bringing the total to 490.

The new coronavirus causes severe acute respiratory infection and symptoms usually start with a fever, followed by a dry cough. Most people infected are likely to fully recover - just as they would from a flu.

In other developments:

• The Philippines confirms its third case of the virus, and Australia its 13th. South Korea has two new confirmed cases
• Hong Kong imposes compulsory quarantine on all visitors from mainland China. Health workers in the territory are on strike, demanding the complete closure of the border
• The Hong Kong flagship airline Cathay Pacific asks its staff to take three weeks' unpaid leave
• Organisers of the 2020 Tokyo Olympics say they are "seriously concerned" about the spread of the virus and its possible impact on the games

How did the virus get on board the ship?

There is a much smaller number of cases in countries around the globe other than China - two people outside of mainland China have died of the disease.

The Hong Kong man believed to be the source boarded the cruise ship in Yokohama, Japan, on 20 January, and disembarked in Hong Kong on 25 January. He was only later found to have tested positive for the virus.

Officials on the cruise ship began screening guests on Monday evening, and the vessel was placed under quarantine on Tuesday.

What happens to the passengers now?

Passengers and crew on the ship will now be under quarantine for 14 days. The incubation period of the virus is believed to be around two weeks.

All 10 cases are in those over the age of 50 and one is in their 80s, Japanese broadcaster NHK said.

Two of them are said to be Japanese, and none are in "serious condition", it added.

"We had them [the ones who tested positive] get off the vessel and... we are sending them to medical organisations," Japanese Health Minister Katsunobu Kato said at a news conference on Wednesday.

British tourist David Abel, who is on board, told the BBC he was supposed to return to the UK on Tuesday.

"We had a flight booked with BA on Tuesday morning and that has had to be cancelled. We've got no idea when we are going to be allowed off the ship," he said.

"All we have been informed [sic] is 14 days quarantine on the ship. That means we've got no interaction with other passengers, food is brought to the room. It's really basic food, nothing like we've enjoyed on the cruise at all."

Another passenger said her mother, who is in her 80s, was running out of medicine.

"We are in trouble because [her] medicine is running out. Many of the passengers are old and some are as troubled as we are," she told NHK.

The Diamond Princess cruise ship is part of the Princess Cruises line, owned by British-American cruise operator Carnival Corporation.

There are now 20 confirmed coronavirus cases in Japan, excluding the cruise ship infections.

What about the Hong Kong ship?

Separately on Wednesday, 1,800 passengers and a similar number of crew onboard the World Dream, a cruise ship docked in Hong Kong, are also being tested for the virus.

Local media reports say that three Chinese passengers who had spent time on the ship tested positive for the virus after disembarking.

Passengers developed symptoms on a previous World Dream cruise

The infected passengers were on the ship between 19 to 24 January. Hong Kong health officials say none of those on board had contact with the three passengers.

Some 30 crew members of the cruise ship say they are suffering symptoms of the virus and are also being tested.

(Source: BBC)

What is coronavirus and how worried should we be?

Experts fear latest strain of virus originating in Wuhan may spread across planet from person to person

What is the virus causing illness in Wuhan?

It is a novel coronavirus – that is to say, a member of the coronavirus family that has never been encountered before. Like other coronaviruses, it has come from animals – possibly seafood. Many of those infected either worked or frequently shopped in the Huanan seafood wholesale market in the centre of the Chinese city. New and troubling viruses usually originate in animal hosts. Ebola and flu are examples.

What other coronaviruses have there been?

Severe acute respiratory syndrome (Sars) and Middle Eastern respiratory syndrome (Mers) are both caused by coronaviruses that came from animals. Although Mers is believed to be transmitted to humans from dromedaries, the original hosts for both coronaviruses were probably bats. The first cases of Sars were in China in late 2002. The authorities played them down and were subsequently much criticised because the virus spread virtually unchecked to 37 countries, causing global panic, infecting more than 8,000 people and killing more than 750. Mers appears to be less easily passed from human to human, but has greater lethality, killing 35% of about 2,500 people who have been infected.

Chinese residents wear masks while waiting at a bus station near the closed Huanan seafood wholesale market, which has been linked to new strain of coronavirus. Photograph: STR/EPA

What are the symptoms caused by the Wuhan coronavirus?

The virus causes pneumonia. Those who have fallen ill are reported to suffer coughs, fever and breathing difficulties. As this is viral pneumonia, antibiotics are of no use. Antiviral drugs may be used, but usually only lessen the severity of symptoms. If people are admitted to hospital, they may get breathing support as well as fluids. Recovery will depend on the strength of their immune system. Those who have died are known to have been already in poor health.

Is the virus being transmitted from one person to another?

Human to human transmission has been confirmed by China’s national health commission, although it does not appear to be happening easily as was the case with Sars. As of 22 January the Chinese authorities had acknowledged 440 cases and nine deaths. In the last week, the number of confirmed infections has more than tripled and cases have been found in 13 provinces, as well as the municipalities Beijing, Shanghai, Chongqing and Tianjin. The virus has also been confirmed outside China, in the US, Thailand, South Korea, Taiwan and Japan. The actual number to have contracted the virus could be far higher as people with mild symptoms may not have been detected.

How worried are the experts?

There are fears that the coronavirus may spread more widely and person to person during the week-long lunar new year holidays, which start on 24 January, when millions of Chinese travel home to celebrate. At the moment, it appears that people in poor health are at greatest risk, as is always the case with flu. A key concern is the range of severity of symptoms – some people appear to suffer only mild illness while others are becoming severely ill. This makes it more difficult to establish the true numbers infected and the extent of transmission between people. But the authorities will be keen to stop the spread and will be anxious that the virus could become more potent than it so far appears.

Should we panic?

No. The spread of the virus outside China is a worrying but not unexpected development. It increases the likelihood that the World Health Organization will declare the outbreak to be a public health emergency of international concern when it meets on Wednesday.

There have not been any confirmed cases in the UK at present, but there is definitely potential for cases to emerge due to the volume of international air travel. Those at greatest risk are probably healthcare workers, who might come across someone with respiratory symptoms who had travelled to an affected region. Experts say there is no need for people to change their travel plans at this stage, but basic hygiene measures such as washing hands are sensible.

(Source: The Guardian)

Flu stomps the US, overwhelming ERs and leaving 20 children dead

The flu virus has reached nearly every corner of the nation.

Influenza activity is widespread in all states except Hawaii (and the District of Columbia), according to the weekly flu report released Friday by the US Centers for Disease Control and Prevention.

"Flu is everywhere in the US right now," said Dr. Dan Jernigan, director of the CDC's influenza branch. "This is the first year we've had the entire continental US at the same level (of flu activity) at the same time." It has been an early flu season that seems to be peaking now, he said, with a 5.8% increase in laboratory-confirmed cases this week over last.

There were 11,718 new laboratory-confirmed cases during the week ending January 6, bringing the season total to 60,161. These numbers do not include all people who have had the flu, as many do not see a doctor when sick.

Seven additional pediatric deaths were reported during the week ending January 6, bringing the total for the season to 20.

For older people, the CDC estimates deaths based on pneumonia and influenza. Based on National Center for Health Statistics data, 7% of all deaths that occurred during the week ending December 23 were due to pneumonia and influenza. This is above the rate considered normal for this period, according to Lynnette Brammer, head of the CDC's Domestic Flu Surveillance team.

Additionally, 22.7 hospitalizations for every 100,000 people occurred over the week ending January 6, compared with 13.7 per 100,000 for the week ending December 30. Those older than 65 represent the largest group hospitalized, though people within the 50-to-64 age range and children younger than 5 are also experiencing high rates of hospitalization.

"We are currently in the midst of a very active flu season, with much of the country experiencing widespread and intense flu activity," CDC Director Dr. Brenda Fitzgerald said. "The flu season may be peaking now. We know from past experience it will take many more weeks for flu activity to slow down."

Brammer said, "Basically, it looks like things are starting to level off. We didn't see the sharp increases that we saw the last couple of weeks."

"Over the next few weeks, we'll know if we peaked or not," she said. "I would hope that the areas that have been hit a little bit earlier in the South and up the West Coast, I'm hoping that those people -- particularly some of the states in the South -- may have hit their peak and are on their way down."

Some of the northern states may still be going up in the number of flu cases, she said. "I wouldn't be surprised to see that. But, either way, one of the really important things to remember is there are, probably for everybody, weeks to go in this flu season."

Vaccine effectiveness has not been calculated, but officials know that the most common strain making people sick this year is H3N2, Brammer said.

Jernigan said H3N2 seasons are associated with higher rates of hospitalizations and deaths, as well as with lower vaccine effectiveness. He believes that when calculations are made at season's end, vaccine effectiveness may be around 30% for this season.

Dr. William Schaffner, an infectious disease specialist at Vanderbilt University, provided a nutshell description of this season: "Started early; it then blossomed essentially all over the country more or less simultaneously. The upswing has been dramatic, and essentially the entire country is affected -- some parts more than others -- but flu is everywhere."

Schaffner suspects that holiday travel helped transport the flu virus and expedited its transmission. "All those hugs and kisses ... we're seeing the consequences now."

H3N2, this year's predominant strain, "tends to produce more severe disease, particularly among older persons," Schaffner said. "Doctors' offices, clinics and emergency rooms all over the country are feeling the H3N2 impact right now."

Generally, people most at risk for complications are older people, children and people with weak immune systems.

"Influenza and its complications disproportionately affect people who are 65 and older," Schaffner said. "They account for 80% of the deaths, and then there are also deaths in younger people, often who have underlying illnesses, such as heart disease, lung disease, diabetes, and also in some young children."

Two tragic deaths
However, flu can also claim the lives of healthy adults such as Jenny Ching, 51, who died January 5 after battling what she thought was just a bad cold.

Her husband, Matt Ching, told CNN affiliate WCVB that the Massachusetts resident "had the flu, and she also developed a bacterial infection, and it was just really severe and caused severe pneumonia, and her body just didn't react to antibiotics."

Ching said he wasn't sure whether his wife had gotten a flu shot this season, though in seasons past, that was the norm for the mother of two boys, ages 9 and 7.

Schaffner noted that "the usual flu death is a person who gets influenza, gets all that inflammation in their chest and then has the complication of pneumonia." The flu "can take a perfectly healthy person -- a child, a young adult, robust -- and put them in the ER in 24 to 48 hours."

That was the case for Kyler Baughman, 21, who died unexpectedly December 28 at UPMC Presbyterian Hospital in Pittsburgh. "Robust" characterizes Baughman perfectly.

The Latrobe, Pennsylvania, resident, who often posted pictures of himself at the gym on Facebook, was studying to be a physical trainer and worked not one but two jobs, his mother told CNN affiliate WPXI.

"It doesn't seem real," said his mother, Beverly. She recounted that her son looked run-down when she saw him December 23. On December 26, Baughman went to work but left early because he wasn't feeling well. The next day, he visited the ER at Westmoreland County Hospital. Health personnel immediately decided to fly him to UPMC, where he died less than 24 hours later.

The cause of his death, as reported by the Allegheny County Medical Examiner, was influenza, septic shock and multiple organ failure. Unlike the usual flu death resulting from pneumonia complications, Schaffner said, "this is a different phenomenon."

The viral flu infection stimulated an immune and inflammatory response in Baughman's body. "This happens to everyone," Schaffner noted, but when the person is a "very strong, robust person," there are times when that response is "overwhelming." In such cases, cytokines -- proteins created as part of the inflammatory response -- create a "cytokine storm" in the body. "And this cytokine storm can actually lead to sepsis in the person."

Braugham's parents hope that by sharing his story, they might save someone else.

"I just think he ignored it and thought it would go away, like most people," his mother said. Added his father, Todd: "Don't let things go. Whenever you have fever and you have it multiple days, don't let it go. Get it taken care of."

Different states, different responses
Alabama Gov. Kay Ivey declared a state public health emergency because of the flu on Thursday.

Scott Harris, acting state health officer at the Alabama Department of Public Health, said the influenza outbreak includes high activity throughout the state but particularly in metropolitan areas. This "crush" means some hospitals are operating over capacity, leaving some patients sitting in ERs.

The public health emergency order helps health care professionals manage resources more efficiently and provides leeway so alternative care can be provided when personnel are unable to offer standard care.

"If you're sick, please try to stay home if you can do that and get in touch with your health care provider," Harris said.

On the West Coast, Dr. Jasjit Singh, a pediatric infectious disease specialist at Children's Hospital of Orange County, said 27 influenza-related deaths have occurred in California as of December 30: all among adults under 65 years old.

"It's been an earlier flu season than in years past," Singh said. As of January 6, the hospital has admitted about a quarter of the 303 patients seen with influenza A infections, compared with about 19% of the 89 cases seen last year at this time. Meanwhile, of 78 influenza B cases, about 13% required admission, compared with 22% of 27 cases last year.

Overall, California reported 7,306 laboratory-confirmed cases for the season as of December 30.
Texas, which laboratory-confirmed 5,585 cases of the flu as of that date, is seeing activity levels "at the highest level -- widespread -- for a few weeks," said Lara M. Anton, a press officer for the Department of State Health Services.

Because the Lone Star State counts flu deaths from death certificate codes, there's also a "significant lag" between when a death occurs and when the death is reported, she said. However the majority of deaths this season occurred among people 65 and older.

"There are reports of hospitals throughout the state that have needed to divert non-emergency ambulances for periods of time because of overcrowding in their ER," Anton said. With most hospitals coming off "divert status" within the same day, the state's hospital system has been managing the increased number of patients. The department continues to monitor the situation closely and "will step in with support when it is requested," she said.

Texas is encouraging "anyone with symptoms to stay home and to see their health care provider, as antiviral medications may shorten the duration of their illness," Anton said. Amid an outbreak in San Antonio, one school took that advice to heart and closed Friday for a "flu day."

(Source: CNN)